Jewish tradition in death and dying
Heather M. Ross
Approximately 80% of American lives end in hospitals (Nuland, 1994). Nurses play an incomparable role in patient care, especially through out the dying process. Nurses have more contact with patients and families than any other health care professionals. Nurses also work with the dying outside hospitals in such services as home care and hospice. Apart from ventilators and monitors that define medical intervention to the dying and their families, many individuals lean heavily on their religious faith in their last weeks and days. An awareness of different faiths and traditions can help nurses provide culturally sensitive care to patients and their families as they face their final moments together.
Judaism is a nearly 6,000 year old religion with origins in the Middle East. There are approximately 13 million Jews in the world, with about 5 million residing in the United States alone. Judaism covers a wide spectrum of practices and traditions, from the most observant Orthodox families to the unobservant and unaffiliated. There are many families whose generational gaps have created enormous rifts in religious practice and belief. Just as it is impossible to pinpoint any one type of Jew, it is impossible to present a unified Jewish view and tradition associated with death and dying. However, some general insights about the faith and its perspectives on death can guide clinical care. Familiarity with some traditional thoughts and practices that shape the Jewish dying process can assist nurses in providing comfort and respectful care to the dying Jewish patient and family in a time of many questions and much uncertainty.
Judaism and Life
Any discussion of Jewish health care tradition in death and dying must examine the traditional Jewish considerations of the value of life and its relative quality. Religious duties concerning life always have priority over those connected with death, according to the Talmud, a 3rd to 6th century collection of legal writings and debates which defines Jewish law. Traditional Jewish health care law, as constructed by spiritual leaders called rabbis, concerns patients requesting personal guidance, not general ethical protocols for health care providers. Thus, Jewish law uses situational examples, not a particular ethical system, to illustrate specific legal ideas. Jewish sages in the Talmudic era pondered health care questions, but their thinking was done before the age of CT scans and antibiotics. Today, many Jewish scholars advise that these thinkers’ views be respected, but should not necessarily be followed to the letter.
According to Jakobovits (1959, p. 46), “The value of human life is infinite and beyond measure, so that a hundred years and a single second are equally precious.” As such, traditional Judaism does not consider quality of life as a factor in administering health care. One modern thinker points out, “What might seem a poor quality of life for some may be acceptable for others,” thus discounting quality of life as a factor with respect to health care treatment (Goldman, 1978, p. 266). One cannot use low quality of life as an excuse for withholding treatment or even hastening death (Jacob, 1987). This Jewish view of health care is often in contrast with the American system that takes quality of life as a primary consideration in making end-of-life patient care decisions.
End of Life
When a patient is expected to die in 3 days or fewer, he is termed a goses in traditional Jewish sources. Despite this distinction, a goses is still to be treated as a living person in all respects. In fact, Jewish law does not at all connect the goses state with regulations regarding treatment of the dead. It is prohibited to perform any traditional death preparations on a goses. For example, one must not “tie his jaws, anoint, wash, plug open organs, remove the pillow from underneath him, or place him on the … ground,” as one would do as part of Jewish rituals for a deceased person. Further, society may not act in anticipation of the goses’s death, hence a prohibition against arranging for a coffin or a gravesite before the actual arrival of death. Interestingly, the maximum duration for which one can remain in the goses state is 3 days. After that period, the goses is considered to be dead, and his relatives must mourn for him, since death is assumed to be 3 days or closer when one enters the goses state (Jakobovits, 1959).
Of course, the determination that one lies in the goses state depends upon the health care professional’s ability to predict patient outcome. With the advent of modern technology, prediction of such a state is increasingly difficult. Many treatment options that did not exist when sages defined the goses are available today. This raises many dilemmas. For example, Friedman (1993, pp. 106-107) asked, “In the light of modern technology, does the goses state apply to a patient who would have died without life support, or does it only apply to a patient who will die immediately, even with life support?” The answer depends on the purpose of the treatment. Is the patient receiving artificial life support to improve his chances of survival, or merely to prolong the dying process? Some have suggested that perhaps the definition of a goses should be amended so that a goses is one for whom life support only prolongs his last days on earth, without setting a specific number.
Jewish law contains several principles regulating the treatment of a goses. The foremost of these is the idea that death should approach according to its own schedule. No one should disturb the goses from maximum comfort for fear of either hastening or preventing the natural onset of death. One may, however, remove barriers to death’s natural approach. In addition, health care professionals are not obligated to perform any action which, according to Rabbi Moses Isserles, the 14th century sage, “constitutes a hindrance to the departure of the soul” (Friedman, 1993).
This can be interpreted into modern health care as a prohibition against carrying out unnecessary tests on an individual who is in the midst of his final days. For example, once an individual is no longer receiving curative therapy, he should be allowed to “rest in peace” without being subjected to having blood samples drawn, and extensive monitoring.
Jewish law also identifies a lesser known category of patients faced with terminal disease. That is the condition of terefah, indicating one who is critically ill, but not within 3 days of death. The terefah is, like the goses, ill from a “fatal organic disease, incurable by human agency,” according to the modern teaching of Rabbi Moses Feinstein. However, unlike the condition of goses, time does not constitute the primary factor in defining a terefah (Sinclair, 1989).
In modern Jewish thought, a terefah is distinguished from a goses in terms of the treatment he must receive. Whereas one should strive only for comfort and the natural onset of death when treating a goses, a terefah must be treated “exactly as any other patient would be. Full resuscitative measures must be carried out, even if they will prolong life only for a short while” (Abraham, 1990, p. 13). When considering treatment decisions for dying patients, health care professionals today are most frequently addressing individuals who fall into the category of terefah. Although a terefah will undoubtedly enter the goses state at some point, he deserves the fullest treatment possible up to that point. The difference in treatment goals for a terefah and a goses is a significant example of the way in which Jewish law reconciles the concept of life’s infinite value with the crucial preservation of dignity with death.
Making Treatment Decisions
Two important elements of modem health care are the many choices available to individuals seeking care for serious illness and the determination of who is to make treatment decisions. Contemporary Jewish thought addresses some questions about a patient’s choice to accept or refuse treatment. For example, should an elderly patient be able to refuse dialysis that would prolong his life? The modern Jewish response is that the patient is always encouraged to “heal yourself,” just as the caregiver is obligated to heal the patient. Therefore, Jewish beliefs support the caregiver’s providing treatment to prolong the patient’s life. However, the Jewish patient is not bound to accept any treatment at the expense of dignity in his final days (Goldman, 1978). The following case study illustrates how the nurse can use a knowledge of Jewish faith and traditions to provide culturally competent care.
Mrs. G is a 76 year old with end-stage metastatic cancer. Uncomfortable and frail, she has stopped eating. Her physician tells her that a surgical procedure to insert a jejunostomy feeding tube will prevent her from starving to death in the near term.
According to modern Jewish law, the health care provider is obligated to provide Mrs. G with the option to insert the tube. Mrs. G, however, is not obligated to undergo the procedure. The surgery does not offer any curative treatment, and would detract from palliative measures by causing her discomfort and distraction. Mrs. G may decide that the risk of surgery and prolonging the dying process outweigh the potential benefits. Her Jewish background supports her learning her options and letting her make her own decision to accept or refuse treatment.
Nurses play a critical role in providing end-of-life care. Mrs. G may require home nursing services and emotional support, and she may appreciate the offer of Jewish chaplain services. Sensitive nursing will help to preserve Mrs. G’s dignity in her final days.
Jewish views of death and dying have evolved from Biblical times through the Talmudic era and to today’s age of complex health care technology. Originally, a decision to withhold therapy or refuse treatment would fall under the auspices of euthanasia. The word euthanasia itself means “good death,” from its Greek translation. The concept and option of euthanasia are popularly translated very widely today, and may mean “death with dignity,” more active measures to hasten death, or even physician-assisted suicide.
Traditional Judaism prohibits euthanasia, and considers a patient’s refusal of potentially curative treatment to be equivalent to suicide, which is similarly prohibited. However, Jewish law does distinguish between passive and active forms of euthanasia, with respect to the goses state (Bleich, 1981). The traditional example of the distinction between active and passive euthanasia is the difference between removing a pillow from under the head of a goses and removing the sound of a woodchopper from outside his bedroom.
To remove a pillow from under the head of a dying person entails actively disturbing a resting patient. Actively disturbing a dying man was believed to hasten the departure of his soul, as it disrupts his comfort as death approaches. In ancient times this was considered an act of active euthanasia, and was condemned as plain murder. This practice is no longer so. Keeping patients clean and comfortable are priorities. Today, leaving a patient in one position, possibly resting in his own excretion, can hasten the dying process.
However, removing the sound of a woodchopper from outside a dying person’s window was traditionally considered passive euthanasia. Such an action was not viewed as murder, like active euthanasia. A loud noise such as chopping wood, could distract the goses and prohibit him from slipping comfortably to death. Removing such a disturbing force, then, was akin to removing a hindrance from the natural onset of death. This form of “euthanasia” does not hasten death’s approach, and is not considered to be “shedding blood” as would a direct action that brings the onset of death (Jakobovits, 1959). One medieval example compares this distinction to a flickering candle, which becomes extinguished as soon as one touches it. Even if the patient is agonizing a long time, and he and his kin are in great distress, it is, nevertheless, forbidden to hasten his death, by removing, for instance, the pillows from under his head. Still, if there exists an external cause which prevents the departure of the soul, such as the noise of some pounding, that cause may be removed, since this is not a direct deed to hasten the end, but merely the removal of an obstacle without touching the dying person.
Modern Jewish leaders have extensively considered euthanasia, especially with the advent of such technology as respirators and intravenous feeding methods which can prolong or, having been withdrawn, directly end a patient’s life. One view proposes that passive euthanasia is forbidden by modern Jewish law, noting that “the health care professional is charged with prolonging life no less than with effecting a cure” (Bleich, 1981, p. 75). Abraham (1990, p. 130) declares that “with passive euthanasia, `normal’ procedures must be continued.” For example, a dialysis patient who enters a coma must continue to be dialyzed normally, despite his dim prognosis, as it is a normal procedure for his care. However, artificial nutrition should be discontinued for a comatose patient suffering from end-stage cancer, considering that the patient is a goses and the artificial nutrition, along with curative medications, is not a “normal” procedure and may be hindering death (Goldman, 1978). In a situation like this, some experts contend that it is best to simply stop ordering nutrition and medications for the patient, and simply keep the vein open, rather than to physically remove the intravenous tubes. Such an order is not a direct action to the goses’s body and would not “hasten death,” but rather allow death to approach as naturally as possible (Jacob, 1983).
Withdrawing artificial life support presents very troublesome issues for Judaism as well as for health care professionals today. According to Jacob (1983, p. 271-274), “As long as some form of independent life exists, nothing should be done to hasten death, and all medications which may be helpful must be used. Once this point [of sustaining independent life] has been passed, it is no longer necessary to utilize further technology or drugs.” This statement emphasizes the necessity of determining whether a dying patient can sustain independent life.
In medieval Jewish sources, a patient was considered to have independent life if a feather moved when held to his nose, signifying that the patient was breathing, and therefore alive. This methodology was obviously developed long before the age of mechanical respirators. Today, the accepted method of determining independent life is by measuring brain activity through EEG. This is one more example of how the thought process of traditional Jewish law can be respected, though not necessarily implemented to the letter.
Age and Treatment
In Judaism, there is no traditional discussion of age limit with respect to health care interventions. According to Jewish beliefs, young and old alike are worthy of care. Jewish tradition is concerned solely with saving a life, not with quality of life. As such, ancient and medieval tradition encourages a physician to use all possible health care alternatives for a life-threatening situation, regardless of the patient’s age. However, modern Jewish law again recognizes that medieval Jewish leaders did not have a knowledge of modern health care capabilities. Therefore, modern thought does not encourage the frail elderly to undergo surgery or other rigorous procedures when the physical and psychological benefit and prognoses are doubtful. These elderly patients are encouraged to live out their remaining days with the benefit of palliative therapies (Jacob, 1987).
The frail elderly are not, however, considered as a goses. For example, a 100 year-old woman and a 4 year-old girl, both with end-stage leukemia, would be encouraged only to take advantage of palliative therapies in their final days. Jewish law would not require or encourage either of these patients to undergo aggressive curative therapies that would certainly cause them discomfort in their final days, without significant hope for recovery. Again, contemporary thought acknowledges the importance of avoiding unnecessary suffering, along with the important concept of death with dignity. It is the avoidance of suffering and preservation of dignity that drives important decision making, not age.
Traditional Jewish law prohibited organ donation because a goses would be kept alive past his natural time of death to harvest the organ. Traditional Jewish law also questioned whether it is a good practice to keep one alive unnaturally for an organ harvest that may not even succeed. Another traditional school of thought dictates that organ donation is not permissible, as one must be buried with all of his body intact. In fact, many Jews choose to have an amputated limb buried in the plot that they will eventually occupy so that their bodies will be intact when the Messiah comes. This burial tradition applies only to limbs containing bone and muscle. Therefore, the heart, lung, kidney, cornea, etc., are not “protected categories.”
Jewish belief about organ donation is changing. Many rabbis now believe that organ donation is compatible with Judaism. In particular, many rabbis point to the traditional Jewish teaching that “to save one life is to save the whole world” in support of organ donation. For this reason, many rabbis themselves have “organ donor” listed on their drivers’ licenses. Additionally, traditional concerns about protecting the dignity of the organ donor have proven to be unnecessary. Organ donation as a science and an art has evolved so that both the donor and the recipient may live and die with the utmost dignity.
Once again, traditional Jewish law cannot apply exactly to the world of modern technology. Medieval thinkers could not conceive of current treatments and technologies such that one day a goses would be able to, with a machine, breathe on a feather despite the absence of independent life. Similarly, it is difficult to equate removing a pillow from beneath the head of a goses to turning off a respirator. However, as a living religion, Judaism has evolved over the years. Modern Jewish teaching has tried to reconcile Jewish tradition with modern health care reality.
The Role of Nursing
Nurses play crucial roles in easing the dying process for Jewish families. First, nurses must remember that religious and cultural beliefs and practices surrounding death and dying are factors that affect the experiences of all patients. A simple awareness of traditional Jewish prohibitions against moving or disturbing a goses, and the basic knowledge of modern Judaism’s stance regarding organ donation can do a great deal to help nurses be more sensitive to families’ potential issues about their loved ones’ impending death. Some elements of Jewish tradition may be at odds with basic nursing care. For example, the prohibition against disturbing a goses would traditionally leave the dying to lie undisturbed. A nurse may be able to explain to a concerned family member that changing the patient’s position to avoid skin breakdown, or administering analgesics, is actually keeping him more comfortable than he would be if left alone. This kind of sensitivity and understanding to traditional Jewish belief can result in great relief to the family, as well as the best care possible for the patient.
There are also several traditions associated with the few moments surrounding death which comfort families newly thrust into mourning. Knowing about some of these practices will help in providing sensitive nursing care to the family, even after the patient’s life has closed. As a person breathes his last breath, many Jews will open a window as if to let the person’s spirit escape from the room. This may not always be possible in a hospital. The door may be opened to symbolically achieve the same effect. Close family members may tear their clothes at the moment of death as part of mourning tradition. Another important Jewish mourning tradition prohibits the deceased from being left alone from the time of death until burial. Many families would find comfort in being able to stay by the side of their loved one during that period.
Traditional Judaism prohibits cremation, for the same reason that the body should be buried intact. Judaism also holds mixed feelings with regard to autopsy. The modern stance is that autopsy is permissible only if the results of the procedure will bring medical benefit which may save the life of another.
Judaism also holds many traditions that apply to the week-long mourning period following death. This period is called “shiva” and a family who is in mourning is said to be “sitting shiva.” A Jewish funeral takes place as quickly as possible following the death, preferably within 24 hours of death. Jewish funerals are often held at the gravesite, and end with family members throwing dirt onto the lowered coffin. This symbolic burial by the family officially begins the mourning period. Flowers are not traditionally present at Jewish funerals, as they symbolize life. During this period of shiva, observant Jews remain within their homes, with the mirrors covered; family members sit upon backless stools, and men may not shave. Friends and neighbors traditionally bring food to the family, to ease that burden of their week-long mourning. In addition, observant Jews are required to say a mourner’s prayer, called kaddish, 3 times a day during shiva and for the year following the death of their loved one.
Chaplains are important members of the health care team. Nurses need information about which rabbis are available, the kind of spiritual services they can offer, and how they can be contacted. Jews may not consider consulting a chaplain from another faith as comforting or appropriate. Unlike Catholicism, for example, Judaism does not have a prescribed tradition of “last rites.” Thus, a rabbi does not perform a sacred ritual, as a priest does with the sacrament of extreme unction. Similarly, without a lifelong tradition of confession or mandated regular contact with a rabbi, unaffiliated or less observant Jews may not think to consult a rabbi throughout the dying process, and before planning for the funeral. Though not every Jew is comforted by the presence of a rabbi, many who would not otherwise consult a chaplain do find his or her presence helpful in confronting death and dying.
Many hospitals, home health, and hospice programs have integrated the chaplaincy into the larger team of caregivers, including nurses, physicians, and social workers. Nurses can play an important role in encouraging this integration by getting to know the chaplains at regular interdisciplinary team meetings, and inviting chaplains to speak at nursing conferences about spiritual support during death and dying. The chaplain can be an expert resource in helping to shape guidelines for incorporating spirituality into the basic plan of each patient’s care. In addition, nurses may turn to chaplains for individual or team counseling when coping with the stress and grief that are a part of working with dying patients and their families. Nurses may also find a helpful resource in student chaplains whose training includes time for work with the dying in hospital and community settings
Every nurse must understand that death is approached in unique but powerful ways in Judaism and in all religious and ethnic traditions. Each Jewish patient and family is different. Some will turn to embrace every ancient tradition as a means of coping with death, while others will reject everything that traditional Jewish law teaches. Jewish law and ethics are not firmly based upon any single set of “rules.” Understanding this concept and applying it to end-of-life situations can be frustrating to the caregiver, whose own religious background may carry a defined set of rules for action. Further, Jewish tradition does not define a clear concept of afterlife, as does Christianity and many Eastern religious traditions. For many, this sense of uncertainty is disconcerting and makes the dying process all the more traumatic. Asking Jewish patients and families to explain their religious practices and wishes helps nurses design care that meets each family’s spiritual needs in a culturally sensitive fashion.
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Sinclair, D. B. (1989). Tradition and the biological revolution: The application of Jewish law to the treatment of the critically ill. Edinburgh: Edinburgh University Press.
Heather M. Ross, BA, is a Student in the Advanced Master’s Entry Program, Boston College School of Nursing, Chestnut Hill, MA.
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